《产科并发症英》PPT课件.ppt

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1、LATER PREGNANCY COMPLICATIONSLATER PREGNANCY COMPLICATIONSPremature deliveryPremature deliveryProlonged pregnancyProlonged pregnancyPremature Rupture of Premature Rupture of MembranesMembranes(PROM)(PROM)ContentPRETERM LABOR早早 产产 Preterm Labor:Preterm Labor:Labor occurs after 28 weeks but before 37

2、Labor occurs after 28 weeks but before 37 weeks(ie.196258days)gestation.weeks(ie.196258days)gestation.Infants born during these phase are Infants born during these phase are premature infants.premature infants.The premature infants weight is between The premature infants weight is between 1000 and 2

3、499g.1000 and 2499g.The prognosis of the premature infant is The prognosis of the premature infant is correlated with its gestational age,weight.correlated with its gestational age,weight.Definition:Etiology:1.Obstetric complications 产科并发症产科并发症2.Medical complications 内科并发症内科并发症3.Surgical complicatio

4、ns 外科并发症外科并发症4.Genital tract anomalies 生殖道畸形生殖道畸形1.Obstetric complications:vSevere hypertensive state or pregnancyvAnatomic disorder of the placenta(abruptio placentae,placenta previa)vPremature rupture of membranes vPolyhydramnios or oligohydramniosvMultiple pregnancyvPrevious laceration（裂伤）（裂伤）of

5、cervix or uterus2.Medical complications:vPulmonary or systemic hypertensionvRenal diseasevHeart diseasevInfection:genital tract infection,urinary tract infection,pyelonephritis肾盂肾炎肾盂肾炎,acute systemic infectionvHeavy cigarette smokingvAlcoholism or drug addictionvSevere anemia3.Surgical complications

6、:vConization of cervix宫颈锥切术宫颈锥切术vPrevious incision in uterus or cervix(cesarean delivery剖宫产术剖宫产术)4.Genital tract anomaliesvBicornuate双角双角,subseptate纵隔纵隔,or unicormuate单角单角 uterusvCongenital cervical incompetency先天性宫颈闭先天性宫颈闭合不全合不全Clinical Finding&Diagnosis1.Symptom and SignvUterine contractionsmore t

7、han 2 in one-half hour;vVaginal bleeding-bloody mucous vaginal discharge or“bloody show”;vDilatation扩张扩张 and effacement消退消退 of cervix-change in dilatation or effacement of at least 1cm or a cervix that is well effaced and dilatated(at least 2 cm);2.Laboratory StudiesvCompletely blood count with diff

8、erentialvCervix discharge cultures：should be sent for gonorrhea淋病淋病 and chlamydia衣原体衣原体.vFetal fibronectin纤连蛋白（纤连蛋白（Ffn):negative test is effective at ruling out imminent delivery(within 2 weeks)；positive test（Ffn50ng/ml):result is sensitive at predicting preterm birth.分泌物分泌物3.Accessory examination:

9、vUltrasound examination for fetal size,position,placenta location，and cervical length.Cervical length30nm:prognosticating premature delivery.Infundibulum漏斗漏斗 length of cervical internal os25%Cervical length or vAmniocentesis to ascertain fetal lung maturity,the amnio fluid羊水羊水 be tested for lecithin

10、卵磷脂卵磷脂/sphingomyelin鞘磷脂鞘磷脂(L/S)ratio principle:If the fetus is alive,with no PROM 胎膜早破胎膜早破,fetal distress,or the severe pregnancy complications，the uterine contraction should be inhibited to prolong the gestational age.If premature delivery is unavoidable,something must be done to elevate the surviv

11、al rate of the premature infant.Treatment:1.Bed rest：2.Corticosteroids:to accelerate fetal lung maturity Betamethason 倍他米松倍他米松:12mg IM 1/24 hr 2 doses Dexamethasone地塞米松地塞米松:6 mg IM 1/12 hr 4 doses3.Antibiotics:no benefit in delaying preterm birth.4.Tocolysis：4.Tocolysis Tocolytic therapy should be c

12、onsidered in the patient with cervical dilation less than 3 cm.(1)Beta-Mimetic Adrenergic Agents肾上腺受体激动剂肾上腺受体激动剂 Ritodrine利托君利托君，Terbutaline特布他林，特布他林，salbutamol沙丁胺醇沙丁胺醇：(2)Magnesium sulfate硫酸镁硫酸镁:first line agent for tocolysis;(3)Calcium Channel Blockers钙离子通道拮抗剂钙离子通道拮抗剂;nifedipine硝苯地平硝苯地平(4)Prostagl

13、andin Synthetase Inhibitors前列腺素合成抑制剂前列腺素合成抑制剂 indomethacin吲哚美辛吲哚美辛 Some cases in which preterm labor should not be suppressed.Maternal factors:Fetal factors:Maternal factors:vSevere hypertensive diseasevPulmonary or cardiac diseasevAdvanced cervical dilationvMaternal hemorrhageFetal factors:vFetal d

14、eath or lethal anomalyvFetal distressvIntrauterine infectionvTherapy adversely affecting the fetusvEstimated fetal weight2500gvErythroblastosis fetalisvSevere intrauterine growth retardationManner of labor 1.Vaginal delivery:perineum section会阴切开术会阴切开术 2.Cesarean section:abnormal fetal position胎位异常胎位

15、异常 fetal distress胎儿窘迫胎儿窘迫 maternal hemorrhage孕妇出血孕妇出血 severe maternal complications孕妇严重的并发症孕妇严重的并发症 Case File vA healthy 20-year-old pregnant woman,G1P0 at 29 A healthy 20-year-old pregnant woman,G1P0 at 29 weeks gestation present to the labor and delivery area weeks gestation present to the labor a

16、nd delivery area complaining of intermitten abdominal pain.She denies complaining of intermitten abdominal pain.She denies leakage of fluid or bleeding per vagina.Her antenatal leakage of fluid or bleeding per vagina.Her antenatal history has been unremarkable.She has been eating history has been un

17、remarkable.She has been eating and drinking normally.On examination,the fetal heart and drinking normally.On examination,the fetal heart rate tracing reveals a baseline heart rate of 120bpm and rate tracing reveals a baseline heart rate of 120bpm and reactive pattern.Uterine contraction are occuring

18、 every reactive pattern.Uterine contraction are occuring every 3 to 5 min.On pelvic examination,her cervix is 1 cm 3 to 5 min.On pelvic examination,her cervix is 1 cm dilated,90%effaced,and fetal vertex is presenting at-dilated,90%effaced,and fetal vertex is presenting at-1 station.1 station.vWhat i

19、s the most likely diagnosis?Preterm labor.vWhat is your next step in management?Tocolysis,try to identify a cause of the preterm labor,antenatal steroids,and antibiotics.QuestionsPROLONGED PREGNANCY(POSTTERM PREGNANCY)General consideration:vDefinition:Prolonged pregnancy is defined as pregnancy that

20、 has reached 42 weeks of completed gestation from the first day of the LMP or 40 weeks gestation from the time of conception.The maternal risk:Related to extraordinary fetal size:vDysfunctional labor功能障碍性分娩功能障碍性分娩vArrested progress of labor 产程停止产程停止v Fetopelvic disproportion胎盆不称胎盆不称v Cesarean sectio

21、n 剖宫产剖宫产v Labor trauma 分娩损伤分娩损伤Effect to fetus:v Impaired nutritional supply(weight loss,reduced subcutaneous tissue,scaling脱皮脱皮,parchmentlike skin羊皮纸样皮肤羊皮纸样皮肤)-dysmaturity 成熟障碍成熟障碍v Birth injury(shoulder dystocia肩难产肩难产)v Oligohydramnios羊水过少羊水过少 v Fetal distress胎儿窘迫胎儿窘迫vMeconiurn aspiration syndroam

22、e（MAS)胎粪吸胎粪吸入综合征入综合征vAsphyxia neonatorum新生儿窒息新生儿窒息ETIOLOGYProlonged pregnancy may relate to:vDysfunction of estrogen/progesteron(E/P)ratio雌孕激素比例失调雌孕激素比例失调：prostaglandin前列腺素前列腺素,estrogen雌激素雌激素 progestin孕激素孕激素vcephalopelvic disproportion头盆不称头盆不称（cpd):vFetal deformity胎儿畸形胎儿畸形;vGenetic factors遗传因素遗传因素:p

23、lacenta sulfatase deficiency胎盘硫酸酯酶胎盘硫酸酯酶PATHOLOGYvPlacenta:normal or hypofunction功能减退功能减退 vAmniotic fluid:Oligohydramnios羊水过少羊水过少Meconium dye of amniotic fluid羊水粪染羊水粪染vFetus:Fetal macrosomia巨大胎儿巨大胎儿Fetal dysmaturity胎儿成熟障碍胎儿成熟障碍Small-for-date infant小样儿小样儿Diagnosis:1.Confirmation of gestational age:by

24、 referring to records of:vMecial history:LMP,the exact time of conception,ovulate time,et al;vClinical expression:early pregnancy reaction,quickening time,gynecological examination in first trimester,et al;vLaboratory tests:ultrasound:examination,and clinical parameters of early pregnancy(,hCG)2.Jud

25、gment of the placental function:vFetal movement count胎动计数胎动计数:vFetal electrical monitor胎儿电子监护胎儿电子监护:vUltrasound examination超声检查超声检查:vUrine estrogen/creatinine ratio雌激素和肌酐比值雌激素和肌酐比值:vAmnioscopy羊膜镜检查羊膜镜检查:Treatment:Indication of terminal pregnancy:vCervical maturevFetal weigth4000g,or non reaction pat

26、tern of NST,or CST positive(doubtful)vUrine estrogen/creatinine ratio decreasedvFetal movement OligohydramniosvWith eclampsia of pre-eclampsia1.Induced labor:Cervix is mature,bishop score7 When cervix is mature:人工破膜人工破膜Oxytocin,Prasterone普拉睾酮普拉睾酮Prostaglandin前列腺素前列腺素：propess普贝生普贝生(Dinoprostone Suppo

27、sitories地地诺前列酮栓诺前列酮栓）3.Cesarean section:vFailure of induced labor;vArrested progress of labor;vFetal distress;vDisposition;vLarge fetus;vAmniotic fluid is abnormal;vPregnancy complications;vFetal compromise:breech presentation,et al.Premature Rupture of Membranes(PROM)DEFINITIONvThe fetal membrane r

28、upture happens before labor.Premature rupture of membrane can cause preterm labor,prolapse of umbilical cord,and maternal and fetal infection.vThe less the gestational age,the worse the prognosis of the perinatal infant.Essentials of Diagnosis1.History of a gush of fluid from the vagina or watery va

29、ginal discharge;2.Demonstration of amniotic fluid leakage from the cervix.ETIOLOGYvGenital tract pathogenic microorganism upgoing infection:vAmniotic cavity pressure increase:vPressure on fetal membrane is unbalanced;vNutritional factor;vCervical incompetence;vCytokine:Pathology&PathophysiologyvPret

30、erm laborvProlapse of the umbilical cordvPlacenta abruptionvIntrauterine infectionvChorioamnionitisDIAGNOSIS1.SymptomvSudden gush of fluid or continued leakagevThe color and consistency of the fluid and the presence of Vernix caseosa胎脂胎脂or meconium胎粪胎粪,reduce size of the uterus,and increased promine

31、nce of the fetus to palpation.2.Sterile speculum examinationvPooling:the collection of amniotic fluid in the posterior fornix;vNitrazine test:the nitrazine paper turns blue,demonstrating an alkaline PH(7.0-7.25);vFerning:Fluid from the posterior fornix is placed on a slide and allowed to air-dry.Amn

32、iotic fluid will form a fernlike pattern of crystallization;vvBe care of false negative result:vaginal infections,Be care of false negative result:vaginal infections,presence of blood or semenpresence of blood or semen3.Physical examination:vTo search for other signs for infection.4.Laboratory studi

33、es:vComplete blood count with differentialvUltrasound examination for fetal size and amniotic fluid indexvAmniocentesis to determine fetal lung maturity and the presence of infection5.ChorioamniotisThe most reliable signs of infection include:vFever:the temperature should be checked every 4 hoursvMa

34、ternal leukocytosis:daily leukocyte count and differential.An increase in the white blood cell count or neutrophil count may indicate the presence of intra-amniotice infectionvUterine tenderness:check every 4 hoursvTachycardia:either maternal pulse 100bpm or fetal heart 160 bpm is suspicious.Influen

35、ce on Mother and FetusInfluence on mother:vInfection;vPlacenta abruptionInfluence on fetus:vPremature deliveryrespiratory distress syndrome of newborn新生儿呼吸窘迫综合症新生儿呼吸窘迫综合症vChorioamnionitis绒毛膜羊膜炎绒毛膜羊膜炎aspiration pneumonitis of newborn新生儿吸入性肺炎，新生儿吸入性肺炎，septicemia败血症败血症vprolapse of cord脐带脱垂脐带脱垂fetal dis

36、tressTreatment1.Expectant management:is appropriate for those whose gestational age between 28 and 35 weeks,without chorioamnionitisvGeneral management:bed rest,hydration,clean,patients temperature,heart rate,contraction,vaginal leakage,blood leukocyte count,et al.vAntibiotic:vTocolysis:vCorticoster

37、oids:2.Chorioamnionitis (1)delivery:If chorioamnionitis is present in the patient with PROM,the patient should be actively delivered regardless of gestational age.(2)Broad-spectrum antibiotics3.Term pregnancy without chorioamnionitis:(1)Expectant management:Waiting for patient to go into labor spontaneously;(2)Active management:Induction of labor with an agent such as oxytocin;